Patient Forms
Thank you for your interest in becoming a patient. For your convenience, please print and fill out the forms below so we may serve you more efficiently and minimize your wait time.
Fill out and bring them with you to your first appointment, along with your insurance card and photo ID.
Patient Portal Agreement
Medical Record Release Form
Patient Portal Agreement
Policies
Medication Refill
Please fill out the Medication Refill Request or call your pharmacy for any prescription refill requests. In an effort to provide our patients with the safest, most efficient service possible, we are no longer accepting prescription refill requests by phone. You can also request medication refills through our Patient Portal as well. Before you run out of your medication, please call your pharmacy to request a refill. Your pharmacy will then send us a request with your medication name and dosage. Your provider will then review the request, and a response will be faxed back to the pharmacy. Therefore, it may take 24 to 48 hours for your prescription to be ready. It is wise to notify the pharmacy well before you run out of your medication.
Lab Results, Imaging test, and referrals
Financial Policy
Missed Appointments: Patients who do not show up for their appointment without a call to cancel an office appointment will be considered as NO SHOW. Patients who No-Show more than two (2) times in a 12-month period, may be subject to a $25.00 fee for office appointment No Show fee.
Forms Completion Policy:
You must be an established patient. You may choose to leave the forms, and the doctor will complete them within 5 business days. There will be a $65 fee charge to the patient (cash or credit card), payable upon submission of the forms.